Patient Safety Tip of the Week

February 8, 2011 Inducing Too Early

The Leapfrog Group, in conjunction with multiple partners, has issued a Call to Action to address the striking increase in the number of deliveries being induced prior to 39 weeks without compelling medical indications. Their call to action is accompanied by public release of results of induction rates at 773 hospitals nationwide in their 2010 hospital survey. And, through their partnerships with groups like the March of Dimes, the Childbirth Connection, and the California Maternal Quality Care Collaborative they have made available a number of excellent resources to help hospitals and communities address this growing problem. And the programs are endorsed by a whole host of professional groups.

Despite ACOG guidelines for criteria for inductions and C-sections at gestational age <39 weeks, there has been a relentless increase in the number of induced labors and elective C-sections over the last 2 decades.

If you are like most hospitals or healthcare organizations, you may not readily know your rates for inductions prior to 39 weeks of gestation. They should be part of your quality improvement program. Even those organizations that do include the rates as measurement indicators may not have a breakdown by reason for early induction. So if you don’t know today, you better get started now.

The March of Dimes site provides a downloadable “Less than 39 weeks toolkit” that was developed by the March of Dimes, California Maternal Quality Care Collaborative and the California Department of Public Health; Maternal, Child and Adolescent Health Divisions, plus a clinician slide deck presentation, and resources for mothers, families, and the public.

They begin by making a compelling case for avoiding induction of labor prior to 39 weeks when no clearcut medical indication exists. The provide the evidence base that clearly shows increases in a host of complications in neonates delivered prior to 39 weeks and that there appear to be no ill effects on mothers by waiting (for those mothers lacking the conditions specified under indications for early induction). Neonates delivered prior to 39 weeks have higher rates of NICU admissions, respiratory distress syndrome, transient tachypnea of the newborn, ventilator use, sepsis, hypoglycemia and feeding problems. They emphasize that the brain is still undergoing tremendous growth and maturation during weeks 35 to 40 and other organs are also maturing in those final weeks. They also note that even a mature lung profile on amniocentesis does not rule out respiratory difficulty after early induction.

Barriers to reducing rates of early inductions without medical indications include attitudes of both clinicians and patients. Prospective mothers may often look to a scheduled induction because of travel distance to the hospital, desire to have their own obstetrician deliver their baby, desire to be done with being pregnant, and a general perception that there is no harm in early induction. The two most frequently noted clinician barriers are (1) the widely held perception that there is little or no harm to the baby or that there is increase risk of harm to the mother and (2) the “convenience” factor. But other barriers to developing a program to reduce early inductions include time and staff limitations. Hospital leadership must ensure that adequate time is made available for staff to participate in the learning, planning and implementation activities required for a successful implementation. And, lastly, mothers and communities at large must be made aware of the potential harms of early inductions and the benefits to babies of waiting for more gestational maturity.

The clinician slide deck presentation is actually quite good at laying out the evidence base against early inductions and discussing both patient and physician perceptions about early inductions.

The “Less than 39 weeks toolkit” contains specifications for medical conditions that may justify a scheduled delivery prior to 39 weeks of gestation from ACOG, Joint Commission, the National Quality Forum, and Leapfrog.

They also stress the importance of using appropriate criteria for determination of gestational age. Gestational age should be confirmed using one of the ACOG criteria:

• Ultrasound measurement at less than 20 weeks of gestation supports a gestational age of 39 weeks or greater.
• Fetal heart tones have been documented as present for 30 weeks by Doppler ultrasonography.
• It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test.

The resources provide descriptions of quality improvement projects on early inductions that were successfully implemented at Magee Women’s Hospital (in Western Pennsylvania), Intermountain Healthcare, and the Ohio Perinatal Quality Collaborative and hospital case studies from Pamona Valley Hospital Medical Center (California) and Tallahassee Memorial Hospital (Florida). They provide examples of tools utilized in those implementations and a good description of the barriers and challenges met. The tools include samples of forms that can be used at the time of scheduling elective inductions or C-sections and sample policies for hospitals to adopt. The fact that these hospitals and health systems have been able to implement these programs so successfully are examples to others that this can be accomplished. Keys are having good interdisciplinary teams, strong physician and nursing leadership, good data with trending and frequent feedback, plus good awareness and educational programs for professionals, patients, and the community at large. The Childbirth Connection website also has some excellent materials for mothers and professionals.

Informed consent should include a discussion about both the benefits and risks any time an early induction is scheduled. The “Less than 39 weeks toolkit” provides some examples of informed consents for labor induction.

The “Less than 39 weeks toolkit” also provides good discussion on data collection tools, measurement indicators, trend charts, quality improvement and PDSA cycles, and other useful things you’ll need in your implementation.

Ultimately, pressure from the public to optimize labor induction practices may help change the current pattern. The Leapfrog press release was accompanied by publishing of the hospital rates of early induction by state. Leapfrog and its collaborating organizations hope that prospective mothers and families will inquire about rates of early induction when choosing their providers and hospitals. The “Less than 39 weeks toolkit” includes some very good informational materials for mothers and families and the general public.

Resources:

The Leapfrog Group (press release). Newborn Deliveries Are Scheduled Too Early, According to Hospital Watchdog Group. Leapfrog Announces Call to Action: Protect Mothers and Babies from Unnecessary Harm. January 26, 2011

http://www.leapfroggroup.org/news/leapfrog_news/4788210

The Leapfrog Group. Hospital rates of early delivery by state.

http://www.leapfroggroup.org/tooearlydeliveries#State

March of Dimes. Medical resources. Less than 39 weeks toolkit.

http://www.marchofdimes.com/professionals/medicalresources_39weeks.html

Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, and Kowalewski L. Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08-85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; First edition published by March of Dimes, July 2010.

March of Dimes, California Maternal Quality Care Collaborative and the California Department of Public Health; Maternal, Child and Adolescent Health Divisions. Less than 39 weeks toolkit.

http://www.marchofdimes.com/downloads/_39_Weeks_ToolkitREV.pdf

clinician slide deck presentation

http://www.marchofdimes.com/downloads/_39WeeksToolkit_PowerpointPDF.pdf

Childbirth Connection

http://www.childbirthconnection.org/article.asp?ck=10650

for professionals

http://www.childbirthconnection.org/home.asp?Visitor=Professional

http://www.patientsafetysolutions.com

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